Advertisement

Comparison Between Steroid and 2 Different Sites of Botulinum Toxin Injection in the Treatment of Lateral Epicondylalgia: A Randomized, Double-Blind, Active Drug-Controlled Pilot Study

  • Yao-Hong Guo
    Affiliations
    Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
    Search for articles by this author
  • Ta-Shen Kuan
    Affiliations
    Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan

    Department of Physical Medicine and Rehabilitation, College of Medicine, National Cheng Kung University, Tainan, Taiwan
    Search for articles by this author
  • Kuan-Lin Chen
    Affiliations
    Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan

    School of Occupational Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
    Search for articles by this author
  • Wei-Chih Lien
    Affiliations
    Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
    Search for articles by this author
  • Pei-Chun Hsieh
    Affiliations
    Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
    Search for articles by this author
  • I-Chieh Hsieh
    Affiliations
    Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
    Search for articles by this author
  • Szu-Hao Chiu
    Affiliations
    School of Medicine, Chung Shan Medical University, Taichung, Taiwan
    Search for articles by this author
  • Yu-Ching Lin
    Correspondence
    Corresponding author Yu-Ching Lin, MD, MSc, Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, 138 Sheng-Li Rd, Tainan 704, Taiwan, R.O.C.
    Affiliations
    Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan

    Department of Physical Medicine and Rehabilitation, College of Medicine, National Cheng Kung University, Tainan, Taiwan

    Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan
    Search for articles by this author
Published:September 22, 2016DOI:https://doi.org/10.1016/j.apmr.2016.08.475

      Abstract

      Objective

      To compare the effects of 2 different injection sites of low doses of botulinum toxin type A with steroid in treating lateral epicondylalgia.

      Design

      Double-blind, randomized, active drug-controlled trial.

      Setting

      Tertiary medical center.

      Participants

      Patients with lateral epicondylalgia for >6 months were recruited from a hospital-based outpatient population (N=26). A total of 66 patients were approached, and 40 were excluded. No participant withdrew because of adverse effects.

      Interventions

      Patients were randomly assigned into 3 groups: (1) botulinum toxin epic group (n=8), who received 20U of botulinum toxin injection into the lateral epicondyle; (2) botulinum toxin tend group (n=7), who received 20U of botulinum toxin injected into tender points of muscles; and (3) steroid group (n=11), who received 40mg of triamcinolone acetonide injected into the lateral epicondyle.

      Main Outcome Measures

      A visual analog scale, a dynamometer, and the Patient-Rated Tennis Elbow Evaluation were used to evaluate the perception of pain, maximal grip strength, and functional status, respectively. Outcome measures were assessed before intervention and at 4, 8, 12, and 16 weeks after treatment. The primary outcome measure was a visual analog scale.

      Results

      At 4 weeks after injection, the steroid group was superior to the botulinum toxin tend group in improvement on the visual analog scale (P=.006), grip strength (P=.03), and Patient-Rated Tennis Elbow Evaluation (P=.02). However, these differences were not observed at the 8-, 12-, and 16-week follow-up assessments. There was no significant difference between the steroid and botulinum toxin epic groups.

      Conclusions

      Injections with botulinum toxin and steroid effectively reduced pain and improved upper limb function in patients with lateral epicondylalgia for at least 16 weeks. The onset of effect was earlier in the steroid and botulinum toxin epic groups than in the botulinum toxin tend group.

      Keywords

      List of abbreviations:

      BoNT (botulinum neurotoxin), BoNT-A (botulinum toxin type A), PRTEE (Patient-Rated Tennis Elbow Evaluation), RCT (randomized controlled trial), VAS (visual analog scale)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Shiri R.
        • Viikari-Juntura E.
        • Varonen H.
        • Heliovaara M.
        Prevalence and determinants of lateral and medial epicondylitis: a population study.
        Am J Epidemiol. 2006; 164: 1065-1074
        • Roquelaure Y.
        • Ha C.
        • Leclerc A.
        • et al.
        Epidemiologic surveillance of upper-extremity musculoskeletal disorders in the working population.
        Arthritis Rheum. 2006; 55: 765-778
        • Nimura A.
        • Fujishiro H.
        • Wakabayashi Y.
        • Imatani J.
        • Sugaya H.
        • Akita K.
        Joint capsule attachment to the extensor carpi radialis brevis origin: an anatomical study with possible implications regarding the etiology of lateral epicondylitis.
        J Hand Surg Am. 2014; 39: 219-225
        • Krogh T.P.
        • Bartels E.M.
        • Ellingsen T.
        • et al.
        Comparative effectiveness of injection therapies in lateral epicondylitis: a systematic review and network meta-analysis of randomized controlled trials.
        Am J Sports Med. 2013; 41: 1435-1446
        • Coombes B.K.
        • Bisset L.
        • Vicenzino B.
        Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials.
        Lancet. 2010; 376: 1751-1767
        • Jabbari B.
        • Machado D.
        Treatment of refractory pain with botulinum toxins–an evidence-based review.
        Pain Med. 2011; 12: 1594-1606
        • Kalichman L.
        • Bannuru R.R.
        • Severin M.
        • Harvey W.
        Injection of botulinum toxin for treatment of chronic lateral epicondylitis: systematic review and meta-analysis.
        Semin Arthritis Rheum. 2011; 40: 532-538
        • Galvin R.
        • Callaghan C.
        • Chan W.S.
        • Dimitrov B.D.
        • Fahey T.
        Injection of botulinum toxin for treatment of chronic lateral epicondylitis: systematic review and meta-analysis.
        Semin Arthritis Rheum. 2011; 40: 585-587
        • Coombes B.K.
        • Bisset L.
        • Brooks P.
        • Khan A.
        • Vicenzino B.
        Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial.
        JAMA. 2013; 309: 461-469
        • Lin Y.C.
        • Shieh J.Y.
        • Cheng M.L.
        • Yang P.Y.
        Botulinum toxin type A for control of drooling in Asian patients with cerebral palsy.
        Neurology. 2008; 70: 316-318
        • Jankovic J.
        • Brin M.F.
        Therapeutic uses of botulinum toxin.
        N Engl J Med. 1991; 324: 1186-1194
        • Wu T.
        • Fu Y.
        • Song H.X.
        • Ye Y.
        • Dong Y.
        • Li J.H.
        Effectiveness of botulinum toxin for shoulder pain treatment: a systematic review and meta-analysis.
        Arch Phys Med Rehabil. 2015; 96: 2214-2220
        • Morre H.H.
        • Keizer S.B.
        • van Os J.J.
        Treatment of chronic tennis elbow with botulinum toxin.
        Lancet. 1997; 349: 1746
        • Keizer S.B.
        • Rutten H.P.
        • Pilot P.
        • Morre H.H.
        • van Os J.J.
        • Verburg A.D.
        Botulinum toxin injection versus surgical treatment for tennis elbow: a randomized pilot study.
        Clin Orthop Relat Res. 2002; 401: 125-131
        • Wong S.M.
        • Hui A.C.
        • Tong P.Y.
        • Poon D.W.
        • Yu E.
        • Wong L.K.
        Treatment of lateral epicondylitis with botulinum toxin: a randomized, double-blind, placebo-controlled trial.
        Ann Intern Med. 2005; 143: 793-797
        • Pullman S.L.
        The myriad uses of botulinum toxin.
        Ann Intern Med. 2005; 143: 838-839
        • Paterson K.
        • Lolignier S.
        • Wood J.N.
        • McMahon S.B.
        • Bennett D.L.
        Botulinum toxin-A treatment reduces human mechanical pain sensitivity and mechanotransduction.
        Ann Neurol. 2014; 75: 591-596
        • Matak I.
        • Rossetto O.
        • Lackovic Z.
        Botulinum toxin type A selectivity for certain types of pain is associated with capsaicin-sensitive neurons.
        Pain. 2014; 155: 1516-1526
        • Meng J.
        • Wang J.
        • Steinhoff M.
        • Dolly J.O.
        TNFα induces co-trafficking of TRPV1/TRPA1 in VAMP1-containing vesicles to the plasmalemma via Munc18-1/syntaxin1/SNAP-25 mediated fusion.
        Sci Rep. 2016; 6: 21226
        • Kim D.W.
        • Lee S.K.
        • Ahnn J.
        Botulinum toxin as a pain killer: players and actions in antinociception.
        Toxins (Basel). 2015; 7: 2435-2453
        • Matak I.
        • Bach-Rojecky L.
        • Filipovic B.
        • Lackovic Z.
        Behavioral and immunohistochemical evidence for central antinociceptive activity of botulinum toxin A.
        Neuroscience. 2011; 186: 201-207
        • Namazi H.
        A novel molecular mechanism to account for the action of botulinum toxin against lateral epicondylitis.
        Int J Rheum Dis. 2008; 11: 83-84
        • Hayton M.J.
        • Santini A.J.
        • Hughes P.J.
        • Frostick S.P.
        • Trail I.A.
        • Stanley J.K.
        Botulinum toxin injection in the treatment of tennis elbow. A double-blind, randomized, controlled, pilot study.
        J Bone Joint Surg Am. 2005; 87: 503-507
        • Placzek R.
        • Drescher W.
        • Deuretzbacher G.
        • Hempfing A.
        • Meiss A.L.
        Treatment of chronic radial epicondylitis with botulinum toxin A. A double-blind, placebo-controlled, randomized multicenter study.
        J Bone Joint Surg Am. 2007; 89: 255-260
        • Lin Y.C.
        • Tu Y.K.
        • Chen S.S.
        • Lin I.L.
        • Chen S.C.
        • Guo H.R.
        Comparison between botulinum toxin and corticosteroid injection in the treatment of acute and subacute tennis elbow: a prospective, randomized, double-blind, active drug-controlled pilot study.
        Am J Phys Med Rehabil. 2010; 89: 653-659
        • Palmer K.
        • Walker-Bone K.
        • Linaker C.
        • et al.
        The Southampton examination schedule for the diagnosis of musculoskeletal disorders of the upper limb.
        Ann Rheum Dis. 2000; 59: 5-11
        • Brin M.F.
        • James C.
        • Maltman J.
        Botulinum toxin type A products are not interchangeable: a review of the evidence.
        Biologics. 2014; 8: 227-241
        • Ravenni R.
        • De Grandis D.
        • Mazza A.
        Conversion ratio between Dysport and Botox in clinical practice: an overview of available evidence.
        Neurol Sci. 2013; 34: 1043-1048
        • Scott J.
        • Huskisson E.C.
        Graphic representation of pain.
        Pain. 1976; 2: 175-184
        • Smidt N.
        • van der Windt D.A.
        • Assendelft W.J.
        • et al.
        Interobserver reproducibility of the assessment of severity of complaints, grip strength, and pressure pain threshold in patients with lateral epicondylitis.
        Arch Phys Med Rehabil. 2002; 83: 1145-1150
        • Pienimaki T.
        • Tarvainen T.
        • Siira P.
        • Malmivaara A.
        • Vanharanta H.
        Associations between pain, grip strength, and manual tests in the treatment evaluation of chronic tennis elbow.
        Clin J Pain. 2002; 18: 164-170
        • Leung H.B.
        • Yen C.H.
        • Tse P.Y.
        Reliability of Hong Kong Chinese version of the Patient-rated Forearm Evaluation Questionnaire for lateral epicondylitis.
        Hong Kong Med J. 2004; 10: 172-177
        • Fritz C.O.
        • Morris P.E.
        • Richler J.J.
        Effect size estimates: current use, calculations, and interpretation.
        J Exp Psychol Gen. 2012; 141: 2-18
        • Rose N.E.
        • Forman S.K.
        • Dellon A.L.
        Denervation of the lateral humeral epicondyle for treatment of chronic lateral epicondylitis.
        J Hand Surg Am. 2013; 38: 344-349